Portrait Share 80/2500 Plus Rx & Unlimited Doctor Visit Copay Health Insurance Plan Details

	Portrait Share 80/2500 Plus Rx & Unlimited Doctor Visit Copay

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
$35 copay
Office Visit for Specialist
$50 copay
Coinsurance
20% Coinsurance after deductible
Separate Prescription Drugs Deductible
$500 Individual
Applies to Levels 2, 3, 4
Prescription Drugs
Rx Deductible for Levels 2, 3, 4
Level 1: $15 copay
Level 2: $35 copay
Level 3: $55 copay
Level 4: 25% copay up to $2500 maximum out of pocket.
Levels based on specific drug
Health Savings Account (HSA) Eligible
No
Out-of-Network Coverage
Yes (Details in plan brochure below)
Out of Country Coverage
Emergency Care Only. Paid as out-of-network, and member must submit an itemized bill with services rendered and a diagnosis in order to be reimbursed.

Periodic Health Exam
20% Coinsurance/No Deductible;
To $300/Calendar Year Preventive Care Maximum; No Waiting Period
Periodic OB-GYN Exam
Exam/Pap Smear/Mammogram:
20% Coinsurance/No Deductible; No Waiting Period
Well Baby Care
Child Exam & Immunizations (age 6-18): 20% Coinsurance/No Deductible; to $300/Calendar Year Preventive Care Maximum;
Immunizations (birth to age 6): 20% Coinsurance/No Deductible;
No Waiting Period

Emergency Room
$75 Copay (waived if admitted) plus 20% Coinsurance after deductible
Outpatient Lab/X-Ray
First $200 per cal year at 0% Coinsurance, then 20% Coinsurance after deductible
Outpatient Surgery
20% Coinsurance after deductible
Hospitalization
20% Coinsurance after deductible

Chiropractic Coverage
20% Coinsurance after deductible.
No Visit Limit (Combined with Physical, Occupational, Speech, Cognitive and Audiology Therapy)
Mental Health Coverage
50% Coinsurance after deductible.
$2500/Calendar Year Maximum. Outpatient care not to exceed $500 of the $2500 Calendar Year Maximum;
(Combined Mental Disorders/Alcohol and Chemical Dependence Calendar Year Max)
No waiting period